Blood Pressure

Blood Pressure Submission Form

Your Name:*

Your Date of Birth:*

Please remember that for most blood pressure medications it is important that you have an annual blood test. Please call into reception and use our Patient Pod which will take your blood pressure and automatically submit it to your records or ring to book an appointment with one of our HCA's if you think you are due one.

Do you suffer from any side effects caused by your blood pressure medication?*

Yes

No

If you have your own blood pressure machine and would like to submit your readings please do so here:

NB please take your blood pressure 3 times and submit ALL 3 readings. Remember to ensure that you are relaxed, sitting down and do not talk whilst taking your blood pressure readings.

1st blood pressure reading (please enter ***/** (for example 140/90)*

2nd blood pressure reading*

3rd blood pressure reading*

Please select your current smoking status from the drop down list*

If you are ready or thinking about stopping smoking for further information and support please visit our NHS Smokefree Support Service page which can be found under the Services heading on our main menu.